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NPI Code Detail

MEDICARE: MYRTHA ST VICTOR

MEDICARE: MYRTHA ST VICTOR
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1164W00000XLicensed Practical NursePN 5195617FL

General Provider Information

NPI Number : 1629378427
Entity Type Code : Individual
Provider Name (Legal Business Name) : MYRTHA ST VICTOR
Provider Business Mailing Address
First Line : 1259 SE NANCY LN
Second Line :
City : PORT SAINT LUCIE
State : FL
Zip : 34983-3119
Country : US
Telephone Number : 772-359-6787
Fax Number :
Provider Business Practice Location Address
First Line : 1259 SE NANCY LN
Second Line :
City : PORT SAINT LUCIE
State : FL
Zip : 34983-3119
Country : US
Telephone Number : 772-359-6787
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 10/26/2010
Last Update Date : 12/29/2010

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Directions to “ MYRTHA ST VICTOR ” Practice Location

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